Article Text

Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury
  1. Kristin Salottolo1,
  2. Ripul Panchal2,
  3. Robert M Madayag3,
  4. Laxmi Dhakal4,
  5. William Rosenberg5,
  6. Kaysie L Banton6,
  7. David Hamilton7,
  8. David Bar-Or1
  1. 1Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
  2. 2Neurosurgery, Medical Center of Plano, Plano, Texas, USA
  3. 3Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
  4. 4Neurosurgery, Wesley Medical Center, Wichita, Kansas, USA
  5. 5Neurosurgery, Research Medical Center, Kansas City, Missouri, USA
  6. 6Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
  7. 7Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado, USA
  1. Correspondence to Dr David Bar-Or; dbaror{at}


Background The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories.

Methods The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850–854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves.

Results The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3–8, 9–12, 13–15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients.

Discussion We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury.

Level of evidence III epidemiologic/prognostic.

  • brain injuries
  • traumatic
  • Glasgow Coma Scale
  • geriatrics
  • mortality

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors KS conceived the study. KS and DB-O designed the study. KS performed data analysis and RP, RMM, and DB-O contributed to data analysis. LD, KLB, DH and WR provided interpretation of the data. KS drafted the manuscript. RP, LD, RMM, KLB, DH, WR, and DB-O provided critical revisions, administrative support, and final approval of the submitted manuscript.

  • Funding Internal funding provided by Swedish Medical Center, St. Anthony Hospital, Medical City Plano, Penrose-St. Francis Medical Center, Wesley Medical Center, and Research Medical Center Kansas City.

  • Disclaimer The American College of Surgeons is not responsible for any claims arising from works based on the original data, text, tables, or figures.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study did not require IRB approval because the analysis of secondary, de-identified, publicly available data does not constitute research involving human subjects under the federal Common Rule, 45 CFR Part 46.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. The datasets used and/or analyzed during the current study are publicly available. The NTDB remains the full and exclusive copyrighted property of the American College of Surgeons.